The Neurological Exam

By Attorney Gordon S. Johnson, Jr.

The neurological exam is an effort at looking for a footprint of pathology, that something about the way in which the brain is functioning is not proper. A full neurological exam includes not only the classic tests to determine whether the nervous system is working properly, but also a rudimenatary assessment of cognitive function and most important, a clinical interview. Yet far too often in concussion cases, the exam is limited to a quick check for focal neurological deficits. Such an exam will rarely identify the type of deficits typically associated with a subtle brain injury, although the diligent neurologist may uncover focal deficits, which were missed at the time of the injury. Sadly, the one focal deficit which is most likely to be effected by a concussion, the sense of smell, is the one which is least often checked.

The neurological exam is often thought of as a objective evaluation as to whether the nervous system is working properly. While this conception may often be the way in which the exam is used for diagnostic purposes, the neurological exam is no more objective than other footprint type evaluations, nor is the good examination, limited to a physical exam.

The proper neurological exam, regardless of what type of physician performs it should also include a detailed history and also a basic test of cognitive function. Perhaps more important, the physical aspect of the exam should should be a diligent, and detailed evaluation. It should include examined the following parts:

• The movements and reactions of the eye.
• An examination of the eye using an ophthalmoscope.
• A test of smell, of each nostril. This is particularly important in concussion cases, as a compromised sense of smell can be an indicator of frontal lobe damage. Sadly, this is the part of the test most often neglected.
• The patient should be asked to whistle, smile and clenching his teeth.
• Hearing should be tested.
• The muscles required to move the head around should be palpatated.
• Then the patient is asked to do the classic hand and arm movements, in order to elicit evidence of tremors, unilateral or bilateral motor weakness and to evaluate coordination and position sense.

The focus of a neurological exam is usually the nervous system, with a particular emphasis on the cranial nerves. The Cranial nerves are nerves which branch off of the brain stem, and primarily control the functions which are within the head. The following are the cranial nerves:

• I. Olfactory - Smell.
  Insist that your neurologist checks this is you have any basis for concern.
• II. Optic - Vision.
• III. Oculomotor - Eye movement.
• IV. Trochlear - Eye movement.
• V. Trigeminal - Controls the muscle and senses of the face.
• VI. Abducens - Eye movement.
• VII. Facial - Taste, expression and facial and scalp movements.
• VIII. Vestibulolocochlear - Hearing and vestibular system.
• IX. Glassopharyngeal - Gag reflex, taste, throat and sinus reflex.
• X. Vagus - throat, voice, gag reflex, coughing, dilations of the stomach.
• XI. Accessory - rotate head, shrug shoulder, raising chin.
• XII. Hypoglossal - muscles of the tongue.

For a chart showing structures of the lower brain and brain stem and the cranial nerves which are connected to them, and the functions these serve, click the link below.

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